6.09. MENTAL HEALTH THERAPEUTIC BEHAVIORAL SERVICES

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1 6.09. MENTAL HEALTH THERAPEUTIC BEHAVIORAL SERVICES Description of Service Therapeutic Behavioral Services (TBS) are provided by Early and Periodic Screen Diagnosis and Treatment (EPSDT) providers as approved under Maryland Law (COMAR ). TBS is a rehabilitative referred service for children and adolescents under 21 years of age. TBS is designed to provide rehabilitative treatment interventions to reduce or improve the target maladaptive behaviors, improve behaviors and where necessary to maintain the improved behaviors though the restoration of a participant to his or her best possible functional level. The services provide the participant with behavioral management skills to effectively manage the behaviors or symptoms that place the participant at risk for a higher level of care. The goal of these services is to restore the participant's previously acquired behavior skills and enable the participant to develop appropriate behavior management skills. Participant Eligibility Participants with MA, PBHS-eligible Medicare participants, and Uninsured-Eligible participants are eligible for TBS and must be under 21 years of age. Service Providers The following provider types are authorized as therapeutic behavioral service providers: A Developmental Disabilities Administration provider meeting criteria set forth in COMAR An outpatient mental health clinic approved under COMAR A mental health mobile treatment unit meeting criteria set forth in COMAR or

2 A psychiatric rehabilitation program approved under COMAR Authorization Process To obtain initial authorization for an assessment for TBS, the provider needs to submit a pre-authorization request in ProviderConnect. The provider must submit a TBS referral form, signed by a licensed clinician, as well as a recent psychosocial assessment. The referral may either be a diagnostic evaluation or a psychosocial summary, signed by a licensed clinician. If the clinician is a graduate-level clinician, i.e. LGSW or LGPC, the form must be co-signed by the supervising, independently licensed clinician, i.e. LCSW- C or LCPC. If the level of care requested is medically necessary, 4 units of TBS assessment will be authorized by Beacon. TBS units are 15-minute increments of time; therefore, 4 units is equivalent to one hour. If, after the assessment, the provider believes that the participant would benefit from TBS services, the provider should submit a request for TBS service in ProviderConnect, detailing the information obtained from the assessment. If the level of care is medically necessary, TBS will be authorized by Beacon. Providers should propose a number of hours of service per week to serve the participant. It is expected that there will be a decrease in hours in proportion to the participant s progress. An initial authorization is for 56 calendar days. Providers may bill for an additional assessment within two weeks of the end date of the 56 days. Providers obtain authorization for the additional assessment through the submission of a Continuing Review Authorization Request via ProviderConnect. This is not a medical necessity review, so clinical information does not need to be submitted to obtain the assessment authorization request. Four units will be authorized for a one month range, starting on the date of the authorization request submission in ProviderConnect. If, after the second assessment, the provider feels the participant needs additional TBS services, the provider will submit results of the assessment with a Continuing Review Authorization Request via Provider Connect. If the level of care is medically

3 necessary, TBS may be authorized for up to 56 days at the hours requested by the provider, and as determined to be medically necessary. Authorization may only be given if the therapeutic behavioral service continues to be effective, and progress towards the specified goals is documented. The same process will be used for future assessments and authorizations as well. If a Beacon Care Manager is not able to authorize the service as medically necessary, the request for services will be referred to a Beacon Physician Advisor for review. If the services requested do not meet medical necessity criteria and are non-authorized, the determination of the non- authorized case will be communicated both via ProviderConnect and telephonically to the provider (refer to Chapter 10 on Grievances and Appeals for further information). Providers are expected to initiate discharge planning at the beginning of service delivery. Providers are also required to submit the discharge plan in the authorization request. Service Rules Services are provided by therapeutic behavioral aides who work in the home and community with both the parent/guardian and the participant. The parent/guardian or the individual who customarily provides care must be present during the provision of services to participate in the behavioral plan unless there are clinical goals specifically addressed in the behavioral plan that require them not to be present. Therapeutic behavioral aides are health care professionals or nonprofessionals who are supervised by an individual who is licensed or certified, or who are otherwise legally authorized to provide mental health services independently. Aides must be trained and supervised by an independently licensed clinician to implement a behavior plan. Aides render services on-site to provide one-to-one behavioral assistance and interventions to accomplish outcomes specified in the behavioral plan.

4 Behavioral plans are developed after a comprehensive therapeutic behavioral assessment is conducted. The assessment must be conducted with the participant present, and is performed by a licensed or certified health care professional. The assessment must address the medical and behavioral needs for therapeutic behavioral services, and includes the risk of needing placement in a more restrictive living arrangement because of the behavior. TBS providers shall ensure that therapeutic behavioral aides are trained and supervised in principles of behavior change and childhood development, as well as clinically accepted techniques for decreasing or eliminating maladaptive behaviors. If the therapeutic aide is not licensed or certified by a health practice licensure board to practice independently, the licensed healthcare practitioner needs to meet at least once every 2 weeks with the aide to review the progress and develop a behavior plan for the participant. At least once a month, the licensed healthcare practitioner needs to observe the participant s progress with the participant's parent or guardian. The healthcare practitioner needs to provide a written progress note that is completed for each time period that a therapeutic behavioral aide spends with the participant. This should include the location, date, start-and-end-time of service, and the name of the parent or guardian. A brief description of the service should be provided, including a summary of the participant s behaviors or symptoms, and the signature of the behavioral aide. The behavioral plan should define specific interventions to be used to resolve the behaviors or symptoms, including how the aide will implement therapeutic behavioral services. Goals should be defined so as to demonstrate the decreasing frequency of targeted behaviors and any alternative behaviors. Although TBS shall be decreased proportionally when indicated by the participant's progress, it will continue to be authorized when it is medically necessary. If the current goals are not being met, a reassessment should be conducted to identify a new plan, or to obtain new targeted outcomes.

5 Claims Process Request for payment of services shall be submitted in accordance with COMAR TBS providers may not bill for services that are provided in hospitals or crisis residential programs. TBS is not to be used for participants who need services for habilitative, custodial, or activities of daily living. TBS aides cannot be a member of the participant's immediate family or someone who lives in the participant s home. TBS providers may not bill for services that are not conducted face-to-face. TBS providers may not bill for services that are part of another service paid for by the State, such as respite services, broken or missed appointments, or for travel to and from the site of service. Claims for unauthorized services will be denied. For all participants, if the TBS services requested do not meet Medical Necessity Criteria and care is not authorized, please refer to Chapter 10, Grievances and Appeals. Recipients also have the option of requesting a review through an administrative hearing as explained in the documents accompanying the denial letter.